NUR101/NUR 101 HEALTH ASSESSMENT
EXAM 1 LATEST 2026/2027 Fortis
Institute STUDY GUIDE |GRADED A|
ACCURATE SUMMER- FALL
internal factors that affect communication
-liking others
-empathy
-listening
-self awareness
external factors that affect communication
-privacy
-no interruptions
-physical environment
-notetaking
Factors of the physical environment for interview
-use of space
-chair arrangement
-temperature
-noise level
-distracting objects
-lighting
Three phases of the interview
1. Introduction
2. Working phase - gather data w/ open-ended questions, then closed questions
3. Closing - gives the patient one last chance to share concerns or express himself or herself
theraputic communication
Verbal and nonverbal communication techniques that encourage patients to express their feelings and
to achieve positive relationship
Nontherapeutic Communication Techniques
Any method of communication that detracts from the therapeutic relationship.
,direct question that is theraputic
used for obtaining concrete answers about medical history such as procedures
direct question that is nontheraputic
does not allow for relevant information or is a leading question allowing for false answers
the role of assessment as the starting point of all models of clinical reasononing
all health care diagnoses, decisions, and treatments are based on the data collected
how is diagnostic reasoning used in clinical judgement
cues are attended to then hypotheses are formed and data is gathered then each hypothesis is
evaluated with the data that is collected allowing for a complete picture of the patient needs
Nursing Process: Assessment
collect data, use evidence-based assessment techniques, document relevant data
Nursing Process: diagnosis
Compare clinical findings with normal and abnormal variation and developmental events
Interpret data
Identify clusters of clues
Make hypotheses
Test hypotheses
Derive diagnoses
Validate diagnoses
Document diagnoses
nursing process: identification
-identify expected outcomes
-individualize to the person
-identify expected culturally appropriate outcomes
-establish realistic and measurable outcomes
-develop a timeline
nursing process: planning
-Establish priorities based on meeting identified patient care goals
-Develop outcomes and set time frames for meeting proposed outcomes
-Identify relevant interventions and utilize interdisciplinary health care team members in the care
planning process for the patient
-Document plan of care
, Nursing Process: Implementation
- Implement in a safe and timely manner
- Use evidence-based interventions
- Collaborate with colleagues
- Use community resources
- Coordinate care delivery
- Provide health teaching and health promotion
- Document implementation and any modification
nursing process: evaluation
- Progress toward outcomes
- Conduct systematic, ongoing, criterion-based evaluation
- Include patient and significant others
- Use ongoing assessment to revise diagnoses, outcomes, plan
- Disseminate results to patient and family
how is nursing process used in clinical judgement
allows for an ever evolving fluid path of care that uses subjective and objective data to allow for optimal
patient outcomes
what is a novice nurse
no experience and uses rules to guide them
what is a proficient nurse
understands patient situation as a whole rather than a lists of tasks
what is an expert nurse
has an intuitive grasp of a clinical situation and zeros in on the accurate solution
Steps of critical thinking
- IDENTIFY PROBLEM,
-Interpretation-understand info
-Analysis-piece together
-Inference-draw conclusions
-Evaluation-credibility
-Explanation-clarity and restate info
-Self-regulation-aware of own thinking abilities
first level priority
emergent, life threatening & immediate (ABCs)
EXAM 1 LATEST 2026/2027 Fortis
Institute STUDY GUIDE |GRADED A|
ACCURATE SUMMER- FALL
internal factors that affect communication
-liking others
-empathy
-listening
-self awareness
external factors that affect communication
-privacy
-no interruptions
-physical environment
-notetaking
Factors of the physical environment for interview
-use of space
-chair arrangement
-temperature
-noise level
-distracting objects
-lighting
Three phases of the interview
1. Introduction
2. Working phase - gather data w/ open-ended questions, then closed questions
3. Closing - gives the patient one last chance to share concerns or express himself or herself
theraputic communication
Verbal and nonverbal communication techniques that encourage patients to express their feelings and
to achieve positive relationship
Nontherapeutic Communication Techniques
Any method of communication that detracts from the therapeutic relationship.
,direct question that is theraputic
used for obtaining concrete answers about medical history such as procedures
direct question that is nontheraputic
does not allow for relevant information or is a leading question allowing for false answers
the role of assessment as the starting point of all models of clinical reasononing
all health care diagnoses, decisions, and treatments are based on the data collected
how is diagnostic reasoning used in clinical judgement
cues are attended to then hypotheses are formed and data is gathered then each hypothesis is
evaluated with the data that is collected allowing for a complete picture of the patient needs
Nursing Process: Assessment
collect data, use evidence-based assessment techniques, document relevant data
Nursing Process: diagnosis
Compare clinical findings with normal and abnormal variation and developmental events
Interpret data
Identify clusters of clues
Make hypotheses
Test hypotheses
Derive diagnoses
Validate diagnoses
Document diagnoses
nursing process: identification
-identify expected outcomes
-individualize to the person
-identify expected culturally appropriate outcomes
-establish realistic and measurable outcomes
-develop a timeline
nursing process: planning
-Establish priorities based on meeting identified patient care goals
-Develop outcomes and set time frames for meeting proposed outcomes
-Identify relevant interventions and utilize interdisciplinary health care team members in the care
planning process for the patient
-Document plan of care
, Nursing Process: Implementation
- Implement in a safe and timely manner
- Use evidence-based interventions
- Collaborate with colleagues
- Use community resources
- Coordinate care delivery
- Provide health teaching and health promotion
- Document implementation and any modification
nursing process: evaluation
- Progress toward outcomes
- Conduct systematic, ongoing, criterion-based evaluation
- Include patient and significant others
- Use ongoing assessment to revise diagnoses, outcomes, plan
- Disseminate results to patient and family
how is nursing process used in clinical judgement
allows for an ever evolving fluid path of care that uses subjective and objective data to allow for optimal
patient outcomes
what is a novice nurse
no experience and uses rules to guide them
what is a proficient nurse
understands patient situation as a whole rather than a lists of tasks
what is an expert nurse
has an intuitive grasp of a clinical situation and zeros in on the accurate solution
Steps of critical thinking
- IDENTIFY PROBLEM,
-Interpretation-understand info
-Analysis-piece together
-Inference-draw conclusions
-Evaluation-credibility
-Explanation-clarity and restate info
-Self-regulation-aware of own thinking abilities
first level priority
emergent, life threatening & immediate (ABCs)
